Provider Demographics
NPI:1659033637
Name:BASKETT, DOMINIQUE (PT)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:BASKETT
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3817 SHAFTER AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-2628
Mailing Address - Country:US
Mailing Address - Phone:720-272-3068
Mailing Address - Fax:
Practice Address - Street 1:120 LA CASA VIA STE 212
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3007
Practice Address - Country:US
Practice Address - Phone:925-939-8710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT300435225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist